Patient Information

Family Care Clinic location you are registering for:
MM slash DD slash YYYY
MM slash DD slash YYYY

Health Maintenance

Please check if you've had any of the following:
Please check if you've had any of the following vaccines:

Prior Surgical History

Please click the plus sign to the far right to add additional rows as needed.
Type of Surgery
Year Performed
Surgeon Name
 

Family History

Social History

Do you drink?
Do you use tobacco products?
Any illicit drug use?
Do you drink caffeine?
Do you use any of the following?
Do you have routine transportation?
List ALL medications including herbal remedies, vitamins, over-the-counter, street drugs and prescriptions. (Click the plus sign to the far right to add additional rows)
Medication
Dosage
 

OB/GYN History

Do you have irregular or heavy periods?
Have you ever been pregnant?
Do you have or have you ever had any of the following symptoms? (Check all that apply)

To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform my healthcare provider if there are any changes in my health.